Minutes:
March 16, 2006
| Q1. | Who do I contact to resolve DMERC issues? |
| A1. | Palmetto GBA administers the DMERC program in this region. |
| Q2. | What is the status of the 276/277 transaction with Medicare? |
| A2. | This transaction should be functioning correctly. Providers may contact
our EDI Department at 1.866.352.1608 for any specific issues. |
| Q3. | I am seeing a slow down in reimbursement. Are there any system problems that may explain? |
| A3. | We need more information to look into it. |
| Q4. | I am receiving PR-52 denials on my physical therapy claims. What can I do? |
| A4. | All therapy services require one of the following 3 modifiers: GN, GO,
or GP. |
| Q5. | I want to verify that the diagnosis codes that are considered exceptions for physical therapy limitations are on the local LCD. What is NC’s position? |
| A5. | Currently, there is not a Physical Therapy Local Coverage Determination
(LCD) in NC. Any claims submitted with one of the diagnosis codes on the
exceptions list should be submitted with the KX modifier after the beneficiary
has exceeded his/her physical therapy limit. |
| Q6. | Provider wants the proper billing scenario for six “64470” services, and has received denials when billing these before |
| A6. | We need to review the claims in the system. Please fax examples, and
we will research. |
| Q7. | Medicare is paying part of my drug codes but denying the others. |
| A7. | Please fax examples, and we will research. |
| Q8. | Is there currently a Medicaid crossover issue? |
| A8. | Medicaid has received Medicare’s crossover files, but is holding
the crossovers until they have fixed a system issue. |
| Q9. | Q3010 was a valid code for 2005. A9560 replaced this code for 2006. However during the last part of 2005, we began to see claim denials for invalid procedure when submitting Q3010. |
| A9. | Please fax examples, and we will research. |
| Q10. | Can you provide additional details about the discontinuation of the Standard Paper Remit (SPR)? |
| A10. | Effective June 1, 2006 , providers will no longer receive paper remits
if the provider or their clearinghouse also receives the Electronic Remittance
Advice (ERA). |
| Q11. | What is the process if the patient is going to exceed the physical therapy cap, but their diagnosis is not on the automatic exceptions list? |
| A11. | If the provider knows in advance, they need to submit an exception request
with documentation. |
| Q12. | How far in advance should we send this request? |
| A12. | Per CMS, Medical Review has a 10-day turnaround timeframe to review the
request, plus mailing time. |
| Q13. | Do we need to submit a request if the patient’s diagnosis is on the exception list? |
| A13. | No. Just append the KX modifier and submit the claim. |
| Q14. | Many of our patients have switched to Medicare HMO’s. What if they didn’t intend to or want to switch back to traditional Medicare? |
| A14. | Patients may call 1.800.MEDICARE for assistance. They are able to switch
the patient back to traditional Medicare and retro-activate the termination
date of the Medicare HMO, if the patient never intended to switch to the
HMO coverage. |
| Q15. | We are having problems with denials when the patient has terminated their Medicare HMO, but Medicare still shows that the HMO is active. |
| A15. | CMS is aware of this issue. The problem is that the Common Working File
(CWF) has not been updated timely. We can request manual updates when we
made aware that there is an issue, but the beneficiary needs to initiate
the request. |
| Q16. | We are getting incorrect medical necessity denials. Customer Service states we need to send them in with redetermination request form. Is this true? |
| A16. | Providers may utilize the redetermination request form. However, the
best and quickest way to get reimbursed is to simply resubmit your claims
electronically. |
| Q17. | How do we file correctly when we are billing for an anesthesiologist with 2 trips to the operating room on the same day? |
| A17. | Please fax examples, and we will research. |
| Q18. | Other payers want the 93000 code filed without being broke down. When Medicare is secondary do we still need to break it down? We are in HPSA/PSA area. |
| A18. | Yes. But once the July release is in, we will be able to accept the global code even if you are in a HPSA/PSA area and still pay you the bonus. |
